Use the Clean Claim Law to Get Your Payers’ Attention
All 50 states currently have a Clean Claim Law. The effectiveness of the laws varies dramatically ranging from South Dakota which provides for no financial penalty to Texas where the penalty can go up to a requirement on the payer to pay billed charges; that’s right billed charges.
The fundamental concept behind Clean Claim Laws is that insurance companies must respond to a clean claim within a given period (typically 30 days for electronic claims). Systematic utilization of these laws will allow a medical billing service or medical practice to significantly accelerate and increase collections. In order to take advantage of the clean claim law one must have a monitoring system built into your medical billing process that identifies:
1. To which insurance companies does your state’s clean claim law apply (some payers are exempt);
2. The date your practice initially submits each medical claim;
3. When a request for information was received from the payer (if you receive one then it stops the 30 day clock until you respond),
4. Events that restart the clean claim clock (e.g., your office replies to a payer’s information request), and
5. The date when you received the payer’s final adjudication decision.
Planning and constructing the monitoring system can be difficult, but it can have a significant impact on how quickly your claims are paid cleanly. Aggressive users of clean claim laws have actually received calls from payers assuring them that their claims will be process quickly and requesting that complaints be held to give the payer a chance to prove itself.
If you would like to better understand the benefits of implementing a Clean Claim Law tracking system before investing the time and energy into the design and implementation of the system, then run a pilot. Identify a payer that is consistently in violation of the Clean Claim Law. Select 30 to 50 claims from this payer and manually track all of the items outlined above. Once you have some violations, file a report following your state’s guidelines. This process will allow you to better understand what will be required to make such a system a permanent part of your medical billing and see the potential benefit to your practice.
Copyright 2006 by Carl Mays II
